Previously I have voiced objection to some of the health policy pieces from the Harvard surgeon Atul Gawande. You can read old posts I had written in response to his viral sensation from the New Yorker from 2009, "The Cost Conundrum", here and here. I didn't like how the article attempted to place the burden of responsibility for spiraling American health care costs solely on the shoulders of unsavory, profit-driven physicians. The "culture of greed among physicians" was declared to be the enemy and politicians, health insurance and hospital administration lobbyists, Big Pharma, and medical device manufacturers lapped it up. Go after the foul, profit driven doctors, the article seemed to imply, and the problem will be solved. I thought it was an unfair, overly-simplified, factually inaccurate account of the reasons for health care spending in this country. Alas, I was essentially a lone voice in the wilderness. Before you knew it, President Obama was waving a copy of the article above his head as he decried the unscrupulous surgeons out there, lopping off "folks'" legs because they could earn $30 grand that way, rather than the lower paying "alternatives" like diabetes management. It was a surreal, absurdist nightmare display, from the perspective of a physician in the trenches. But it was too late for rebuttal. The debate was over before it even started.

Dr Gawande had another article in the New Yorker last month called "Overkill". This piece is ostensibly about the epidemic of unnecessary medical care that is carried out in this country. This ought to be a fairly uncontroversial proposition: we certainly do too many procedures, order too many expensive tests in the United States. The question is why. And Dr Gawande, in his latest high profile New Yorker piece, offers, um, a sorta rambling wreck of incoherence. We hear about a lady he saw in clinic with a thyroid nodule, unlikely to cause harm or shorten her life, that he tells her would be better off observed rather than sliced out. And he.....goes right ahead and books her for surgery. We read about a guy with back pain who, because of a corporate inside deal, gets to go see a neurosurgeon at a far away certified Center of Excellence for a 2nd opinion, and non operative therapy is recommended rather than surgery and he does well; the implication being that local physicians will always give bad, profit driven advice so you should unceasingly seek a specialist at major tertiary care centers (sorta like the one where Dr Gawande practices!) where all the doctors are magnanimous altruists who cry themselves to sleep every night with regret that they have to deposit a paycheck every 2 weeks for services rendered. We also read about his friend Bruce whose father fainted and, after an extensive workup was determined to need a triple vessel CABG. Unfortunately, he suffered a stroke during the surgery and was never the same. From this anecdote, he segues into a paragraph about a conversation he had with one of the hosts of the dorky public radio show "Car Talk" about how those Quik-E-Lube shops are always trying to "up-sell" the customer during an oil change on new air filters or windshield wipes or exhaust fans or serpentine belts. The analogy, I guess, is to nefarious doctors (like cardiac surgeons who consulted on Bruce's father) who... umm... do the same? Yeah, you have gallstones and RUQ pain. That's one thing. But you also have a right colon. Maybe that should be changed out too??

Gawande's article makes no mention of the deleterious effects of defensive medicine or the profit margins of so called "non profit" hospital conglomerates. It makes no mention of physician income decreases or the fact that most physicians these days are employees rather than entrepreneurial private practitioners. No mention about dwindling reimbursements for commonly performed procedures. No mention of medical device manufacturer profit margins. No mention of the fact that 30% of Medicare spending occurs in the last 6 months of a person's life (from a man who wrote "Being Mortal"!) Once again he treats health care spending in a vacuum, completely dependent on individual physician decision making. And once again, what drives that decision making is personal benefit and greed. It is unfair and incomplete. Now in real life I think Dr Gawande is actually a pretty cool, laid back guy. On Twitter he seems pretty chill. He likes decent bands. He seems to be intellectually curious, lacks the typical Ivory Tower mega-ego, is honest and open, etc etc. But in these pieces, he is doing a real disservice to his profession. With his cherry picked data and skewed anecdotal-based evidence, he makes it easy for the truly rapacious entities in American health care--- Big Pharma, Medical device makers, Hospital conglomerates, the Health Insurance Industry-- to unequivocally blame and demonize the very professionals who provide the bulk of actual value to our unwieldy system. I wish Dr Gawande would stop doing that.

Lionel Messi is unquestionably the greatest footballer of this generation and, arguably, the greatest athlete I have ever seen----apologies to Michael Jordan--- perform in his prime. Watch this goal from the Copa del Rey today:

This is quintessential Messi. One moment he is standing over the ball, in a seemingly harmless position at midfield, the next thing you know you are picking the ball out of the back of the net. How did this come to pass? How did things change so rapidly? When you watch it the first time it's disorienting. It makes no sense. How does that happen? Messi is 50 yards from goal. He is isolated near the sideline with a defender right on him. What the hell just happened? Then you watch it over and over on YouTube. After ten viewings it starts to make sense. After the 20th view, it all makes perfect, ineluctable sense. Of course, you think. What was all the confusion about again? 2+2=4, right? What else was he going to do? Watch it again. He gets the ball and pauses, daring his mark. Then darts to space with a burst to his right, beating his man. Two more defenders converge. He slows. He is triangulated by the defense, it seems. But no panic. It's a tight space; soccer in an elevator. No time to think. The ball is never far from his foot. He acts. A cutback. Another cutback, split the double team. Speed on a diagonal toward goal. Final cutback on the help fullback. Shoot low and hard, with left to right action, graze the post. Goal. Goal. Goal. Watch it again.

This is physical genius. It cannot be taught or learned. The chosen few are born with it, inchoate and undeveloped. They cultivate it. It is midwifed through the development stages and brought forth when mature, with a flourish, astoundingly. It takes our breath away. We can only watch and marvel. Before he mass marketed himself as a purveyor of schmaltzy pseudo-scientific pop psychology, Malcolm Gladwell wrote great piece back in 1999 on the neurosurgeon Charlie Wilson. In it, he compared the innate talents of Dr Wilson--- his sublime spatial recognition of anatomy, his precision in action, his confidence, his sudden Gestalt understanding of where he was and what needed to be done-- with physical geniuses in professional sports, like Wayne Gretzky and Tony Gwynn. The physical genius see things from a different height, a different angle. The game slows down. They have seen it all before in their imagination. Each jaw dropping, awe inspiring play is, to them, no big deal. They were simply reacting to a tendency they had seen before, a configuration of the defense that was all too exploitable, a slight sag of the defender's hips to the left. The physical genius sees and acts on a different level. And it happens so fast in their own minds they are reduced to explaining it with banalities. Well of course that's what I did. What else was I to do in that situation? He gave me the left sideline. The help defense came late and off balance. They underestimated the frontal attack. On their heels. It was easy, really.

The best surgeon I ever saw was this guy. Surgery, like soccer, is a game that requires intelligence, innate skill, diligent practice and dedication, and the gift of spatial imagination. Many surgeons can bring the first three components with them into the OR, but the last one remains elusive except for the select few. Every once in a while I feel that I have performed a laparoscopic cholecystectomy as effortlessly and masterfully as it could possibly be done, by anyone. Sometimes I feel this murmuring presence of beauty when i am operating. But those moments are fleeting. Most operations, at some point, swerve ever so slightly off course. I may have missed a visual cue. I failed to anticipate. A retractor is placed wrong. An obscured vessel branch is shorn. A placed suture is just off; you feel the overwhelming urge to re-do it. You fix it and move on. No harm is done. But the elegance is lost. A struggle ensues. I have to reconnoiter. Reset my lines of sight. See it again. Do it again. I have to grind my way through it. The narrative has been broken. The song skipped. A loud creaking noise from the house that awakes you from sleep. To see the best in action is a gift. Those who never deviate from elegance. Those who see the field from a higher stanchion. Whether it's Lionel Messi thundering down the right sideline or Alex Doolas chipping away at a frozen abdomen or Charlie Wilson whacking out a pituitary in 25 minutes, it is pure Art in motion. Joyce and Hemingway and Larkin and Cezanne have nothing on these guys......

Recently, a patient came in via the ER with jaundice and severe RUQ pain. The ultrasound demonstrated clear evidence of cholecystitis with stones and wall thickening and fluid around the gallbladder. The jaundice was the hang up. Obstructive jaundice in a patient with gallstones always raises the specter of choledocholithiasis (stones in the common bile duct--- CBD), which often requires a secondary procedure to address (ERCP). Well the gentleman got admitted in the middle of the night and when I saw him the next day, his repeat bloodwork revealed improvement in the liver function panel. Furthermore, his CBD was only 3 mm on the US. It seemed likely that if he did in fact have a stone in the duct, it may have already passed into the stomach. So, after consultation with the GI doctor, the patient was booked for a laparoscopic cholecystectomy, with plans to perform an intra-operative cholangiogram in order to definitively assess the duct.

This was late afternoon case. I popped in the umbilical port and insufflated the abdomen. Within 39 seconds I realized this was going to be a grinder of a case. The gallbladder was cloaked beneath a thick drapery of omentum, stuck up against the inferior edge of the liver. Ordinarily that omentum can be fairly easily swept away with a couple of quick maneuvers. But not this time. It was like someone had dumped a bucket of some epoxy resin in the guy's upper abdomen. The omentum wouldn't budge. Strand by strand I had to cauterize the plastered fat from the edge of the liver. Even that wasn't enough. The duodenum soon revealed itself, tented up against the undersurface of the liver. Again, a meticulous peel down dissection ensued. After about 45 minutes I finally saw the makings of actual gallbladder. Now the the gallbladder is usually egg-shaped or at least orb-like, with a tapering toward the cystic duct. This one was shaped more like a Cuban cigar--- long, cylindrical, and of a uniform diameter. The uniform diameter thing is a dangerous quality. We like difference and distinction in surgery, especially when trying to identify critical structures. A long thin gall bladder that fuses downstream with a common duct of equal caliber is frightening to the nth degree. And if only it were that easy. In cases of acute on chronic inflammation, the area of cystic duct/common duct confluence is a fused, woody, fibrotic sheet of adipose and scar tissue. Actual structures remain elusive. Strand by strand you have to slowly reveal the anatomy to yourself.

In tough gallbladder cases I use a principle called zoom in/zoom out. Yeah, it sounds dumb-- like some sort of faux-Zen, Pat Morita issued Karate Kid nonsense. But it works. It's all about attaining the proper balance between close up and far away. You need to be close. You have to see the structures. Each fiber of tissue has to be seen, categorized, defined. You need that camera right up on top of it all. But not all the time. Especially in biliary surgery, the most common cause of error (i.e. CBD injury) is a concept known as "visual perceptual illusion." The surgeon convinces himself that he sees what he wants to see. That strand of tissue he peels away has been defined in his mind. It's only scar, he thinks. A gestalt picture forms in his mind and the reality of the on-going operation is forced to adhere. That's how bile ducts get clipped and sliced. To avoid perceptual error---and the mind will construct an explanatory image spontaneously, you can't stop it from happening--- you have to shake it up, challenge the picture in your mind. Camera in, camera out. See from far, see near. The mind needs variety. Given limited information, it will construct a limited explanatory image. The most accurate representation of reality will occur when the mind is challenged, presented with a multitude of views and forced to reconcile them all. In and out. Push that gallbladder to the right and left. See the posterior space. This is how you do it safely.